FIFTEEN YEARS AGO THIS MONTH, terrorists flew two commercial airliners into the World Trade Center towers in New York City as part of a multi-pronged attack on the United States. When the dust settled, the horrific event had killed 2,606 people in New York, including hundreds of first responders.

Years later, that dust may be pushing the death toll ever higher. According to the Centers for Disease Control (CDC), since the events of 9/11, at least 1,140 people enrolled in the World Trade Center Health Program—first responders, rescue and recovery workers, construction and utility workers, residents—have died, many from cancers and respiratory illnesses that medical professionals attribute in part to the toxic stew of chemicals and substances they inhaled near Ground Zero.

Congress established the WTC Health Program in 2011 to provide free screening, monitoring, and treatment to 9/11 rescue and recovery workers. There are about 48,000 Ground Zero rescue and recovery workers enrolled in the program, administered by the CDC, and another 16,000 enrolled in a separate program administered by the Fire Department of New York (FDNY). Many participants suffer from debilitating respiratory conditions or post-traumatic stress disorder (PTSD). Over time, the government has expanded the number of illnesses covered under the program, as more proof has been gathered that the afflictions are related to exposures at Ground Zero.

In June 2012, more than 50 types of cancer were added to the list of sicknesses covered by the program. That designation has, in part, led to a three-fold increase in the number of reported 9/11-related cancer cases since the beginning of 2014, as responders have come forward to report previous cancer diagnoses. As of the end of June, 5,441 people enrolled in the program are living with cancer diagnoses. Among those, 4,692 are first responders, emergency responders, recovery and cleanup workers, and volunteers. In addition, more than 12,000 WTC Health Program enrollees have been diagnosed with 9/11-related mental health issues; and more 32,000 have been diagnosed with aero-digestive issues, such as asthma, chronic cough, gastroesophageal reflux disorder or chronic obstructive pulmonary disease, connected to the attacks, according to the CDC.

Dr. Michael Crane is an occupational medicine specialist and the medical director of the WTC Health Program at Mount Sinai Medical Center in New York. He has worked closely with 9/11 rescue and recovery workers and treated them for an array of illnesses related to exposures at Ground Zero. Crane sees a dozen or more new cancer certifications of Ground Zero responders each week. Even with more patients reporting past diagnoses, and other factors like an aging population, he says he is “very much convinced, as are my colleagues, that the actual population of 9/11 responders with cancer is increasing. And I don’t think we have them all yet. It’s a very serious issue.”

NFPA Journal spoke with Crane about the WTC Health Program, health trends among rescue and recovery workers at Ground Zero, and the inspiration he takes from the responders he meets every day.

Working with these 9/11 recovery workers and responders, I imagine you’ve had some heart-breaking moments and some inspiring moments. What sticks in your mind?

I’ll never forget the first guy I saw, he was a utility worker, a strapping young guy. He came in to see me one morning the second week of September 2001; he was coughing and had some sinus stuff. This guy was working 12–16 hour shifts down at Ground Zero for his job and then he would change out of his uniform and go back in his civilian clothes to work another six hours searching, trying to do rescue and recovery. I said, ‘Why are you doing that?’ He told me he lost a family member. To me, that encapsulated everything that was happening down there in the beginning and then throughout the cleanup. These guys were totally selfless, altruistic individuals who were also there because their sense of family had taken this huge hit. They had suffered personal losses and the way they were responding to all that grief was to go out and try and serve other people. I talk to these guys 15 years later, even the guys with cancer, and ask, ‘Now that you know what you know, would you still go down there?’ And they say, ‘Absolutely. I would do it again tomorrow in a heartbeat.’

Do we know what these people were exposed to on that site during the attack and in the aftermath, digging on the pile?

After the collapse of the tower, an enormous dust cloud seemed to swallow lower Manhattan. The people walking through that cloud looked like they were coated in plaster. The guys who went there and got in the first day to do rescue and recovery were in that all day, pretty much without protection of any kind. If they had any respiratory protection at all, the filters clogged up really fast in that dust.

We actually don’t know what was in that cloud. Nobody got out there to grab samples to test, so to this day we treat it as though it was an unknown exposure. Literally when the dust settled, we had guys go out with cups, scoop out some dust from various sites, and bring it back to the lab—that’s how we found out what was in it. You name it, you could probably find it in the dust and in the air.

Like what?

We know for certain there was asbestos.

There were polycyclic aromatic hydrocarbons, some metals, lots of fibers, and fiberglass. Then there were other sorts of combustion products from all the burning onsite, the jet fuel from the planes going into the buildings and setting them on fire. There was likely benzene exposure, plus all that stuff burning off and coming off in the smoke.

As a medical and occupational hazard researcher, how do you even begin to study the effects?

If I go to a benzene spill in a factory, I go in knowing the size of the spill, the compound that was spilled, the ventilation and exhaust system in place, the timeframe for the exposure—I know a lot of stuff. [9/11] by comparison is so out of the box. As far as the cancer itself, there were multiple agents in that cloud that can, over the long-term, produce cancer. But we’ll probably never know exactly how this multi-toxic exposure changes the understood effect of these compounds on their own.

How does the center make contact with first responders who were involved with 9/11? How many have you evaluated?

We get a lot of people coming in to the program through word of mouth, and we also do community outreach. I’ve found that if you walk up to police officers who look like they are in their late 30s, invariably they were down at Ground Zero. In my experience, there is maybe a 50 percent chance they had thought about coming to the WTC Health Program and never came. There are lots of folks who haven’t availed themselves of the program yet.

What percentage has come forward and enrolled?

One of the problems from the beginning has been that there was no roster kept of the people who ended up on the site, so nobody knows the number of people who responded. People rushed in, it was chaos. The working guestimate is there were about 90,000 responders. Across our programs, we have about 65,000 folks who we have identified as responders. We’re a little short of where we should be.

There is a list of illnesses that are covered for people enrolled in the WTC Health Program. What is the process for getting the government to pay for treatment once these individuals are diagnosed?

I see a patient, look at their condition, and write out a certification form that describes how their symptoms and conditions are related to the dust and the patient’s exposure at the site. The government is very good about reviewing that and getting it back to us. It takes maybe 10 days, which is really fast compared to workers’ comp or other insurance companies. Once they indicate that the person has a condition that is certified as related to working at the World Trade Center site, treatment for that condition is essentially free to the responder.

As you can imagine, for people who have a cancer that is certified under this program, it is an enormous financial relief to families. Some of these cancer medications can cost $18,000 a month. For a normal family trying to handle that, even with insurance, it’s crippling. You can’t always cure it, but certainly you can relieve some of the tremendous anguish that comes with the diagnosis of cancer.

Other than an apparent increase in cancers, what are some of the other conditions you see in this population? How does it impact their lives?

It is a spectrum of respiratory conditions right now. About 20–30 percent of our population has asthma. For most people it’s a pain in the neck, but it’s not the type of thing where we see people rushing to the emergency room because they can’t breathe. This is a more chronic, lower acuity condition, but it’s really disturbing to people who were used to being active. Many are struggling to do their jobs and stay on the job. Asthma can disqualify people for some of those positions, which is obviously a real hit for some of these guys who’ve spent their careers doing service jobs.

What are some of the more serious conditions?

I have a couple of folks who are on oxygen bottles, who have advanced to the point where they have to take oral medicine like prednisone, a steroid that helps control their pulmonary symptoms. But the medications can wreck havoc on their bodies, and cause bone loss and muscle issues. Long-term it’s very discouraging, because they can become totally disabled.

We have some patients who are getting worse and showing signs of developing interstitial lung disease. Like pulmonary fibrosis, it is a distinctly possible and present disease in this population, though rarely. It usually progresses to the point where patients need a lung transplant. We’ve had a couple of those, and these folks’ lives are very limited.

What would you say to someone reading this or has a friend or loved one who was at Ground Zero who hasn’t yet been screened?

It is a great program, it is confidential, nobody finds out about what happens here. If you are having nightmares or depression, we can help you with that. If you’re coughing or having trouble breathing, we can help. If you’re worried about cancer, we can help. We can help with all sorts of things, and we have funding for years so we can keep doing it. We are honored if you come down and see us, and that’s the truth.

From your work, what are some key observations you can share regarding first responders and workplace safety?

For a scientist and medical doctor like me, one main thing is how important it is to get that pre-employment physical done, including a respiratory test spirometer, so if something does happen we can track the changes in your body and lungs and other parameters.

Another big one is that training and preparation for certain types of situations is critical. For example, if you look across the board at the folks from 9/11 who have PTSD, the rate is a good bit lower for police responders, and
probably lower in firefighters as well, compared to people who weren’t trained as responders. This is probably due in part to the responders’ training and experience. It all argues for responders to get the most specific training they can for anything they might come into contact with: fires, people with firearms, disturbed people. Get trained up front.

JESSE ROMAN is associate editor of NFPA Journal. Top Photograph: AP/Wide World